Healthcare Provider Details

I. General information

NPI: 1629986997
Provider Name (Legal Business Name): SHANNON DODGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7711 NE 175TH ST UNIT B107
KENMORE WA
98028-3575
US

IV. Provider business mailing address

7711 NE 175TH ST UNIT B107
KENMORE WA
98028-3575
US

V. Phone/Fax

Practice location:
  • Phone: 425-359-3829
  • Fax:
Mailing address:
  • Phone: 425-359-3829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number605908945
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: